|Year : 2015 | Volume
| Issue : 2 | Page : 90-92
Cesarean section under spinal anesthesia in a patient of Takayasu's arteritis
Asma Murtaza Khan, Mukul Chandra Kapoor, Archana Puri
Department of Anesthesiology, Saket City Hospital, New Delhi, India
|Date of Web Publication||11-Sep-2015|
Mukul Chandra Kapoor
6 Dayanand Vihar, New Delhi - 110 092
Source of Support: None, Conflict of Interest: None
A young lady with Takayasu's arteritis was scheduled for cesarean section in view of precious pregnancy and intrauterine growth retardation. She was successfully managed under spinal anesthesia as the blood pressure difference between the upper and lower limbs was not significant and as she had no co-morbidities apart from hypertension.
Keywords: neuraxial block, regional anesthesia, Takayasu′s arteritis
|How to cite this article:|
Khan AM, Kapoor MC, Puri A. Cesarean section under spinal anesthesia in a patient of Takayasu's arteritis. J Obstet Anaesth Crit Care 2015;5:90-2
|How to cite this URL:|
Khan AM, Kapoor MC, Puri A. Cesarean section under spinal anesthesia in a patient of Takayasu's arteritis. J Obstet Anaesth Crit Care [serial online] 2015 [cited 2017 Sep 24];5:90-2. Available from: http://www.joacc.com/text.asp?2015/5/2/90/165138
| Introduction|| |
Takayasu's arteritis (TA) is a granulomatous pan-endarteritis of unidentified etiology. Although, it occurs sporadically throughout the world, it has a specific predilection for Asian women in the reproductive age group. , The disease afflicts the arterial system leading to varying degrees of narrowing, occlusion, and dilation, which eventually results in perfusion abnormalities in organ systems. We present the anesthetic management of a patient of TA scheduled for cesarean section. The consent of the patient has been taken for the publication of the case report.
| Case Report|| |
A 31-year-old oriental multigravida (gestations 4, abortions 3) presented with abnormal uterine/umbilical artery Doppler finding at 37 weeks gestation. The fundal height was equivalent to 34 weeks gestation, suggestive of intrauterine growth retardation (IUGR). She was diagnosed to have TA 3 years back and aortography had revealed diffuse narrowing of the abdominal aorta with a peak systolic gradient of 30 mm Hg across the narrowing. She was on regular antihypertensive therapy with amlodipine 5 mg oral once daily. The patient had a bad obstetric history. The first pregnancy was terminated by normal vaginal delivery due to intrauterine death at 24 weeks gestation. The two subsequent pregnancies terminated as first-trimester spontaneous abortions.
Peripheral pulses in all extremities were palpable. Blood pressure was recorded as 140/90 mm Hg in the right upper arm and 130/85 mm Hg in the right leg. Renal function parameters were within normal limits. In view of the precious pregnancy and evidence of IUGR, the patient was scheduled for an early cesarean section.
Preoperatively, the patient was nursed in the left lateral position. Monitoring included five-lead electrocardiography, noninvasive blood pressure cuff in the right upper arm and pulse oximetry. Two large-bore peripheral intravenous (IV) cannula were secured. IV preloading was restricted to 600 ml Ringers lactate. Subarachnoid block (SAB) was administered, in sitting position, using a 26G Quincke needle, via the L2-L3 interspace, with 7.5 mg heavy bupivacaine and 20 mcg fentanyl. The patient was thereafter placed in supine position with left lateral tilt and a pillow under the head. Oxygen was administered using a facemask.
Few minutes after administration of SAB, fall in the blood pressure was observed along with a transient drop in heart rate from 110/min to 64/min. 0.6 mg of atropine was administered IV, which resulted in a rise of the heart rate to 84/min and improved the blood pressure to 104/72 mm Hg. The patient was actively warmed using a forced warm air blower. The pulse plethysmograph tracing was damped throughout the surgery and radial pulses were not palpable. Pulse oximetry failed to display the peripheral oxygen saturation (SpO 2 ) although a dampened plethysmograph was visible. A 2.4 kg baby was delivered, who cried soon after birth and had an APGAR score of 7/10. The SpO 2 was recordable only about 15 min after childbirth. After delivery of the baby, a slow oxytocin IV infusion was administered (10 IU syntocinon in 500 ml Ringers lactate). An IV bolus of syntocinon was not administered. No drop in blood pressure was noted during the remaining procedure.
After observation in postanesthesia care unit for 2 h, the patient was shifted toward. Patient's stay in the hospital was uneventful and was discharged after 2 days. The newborn remained under pediatric care for 3 days after delivery, before discharge.
| Discussion|| |
Although, Mikito Takayasu reported arteriovenous anastomosis like appearance on fundus examination in a young woman in 1908, the term "Takayasu's arteritis" was coined only in 1939.  TA is an autoimmune disease, predominantly afflicting oriental women (8:1), with a peak incidences during the second and third decade of life.  Its prevalence in childbearing age group women suggests a role of sex hormones in its pathogenesis.  Genetic predisposition for TA in families, linked to the presence of HLA-Bw52, and MIC-A gene has been suggested. ,
TA results from infiltration of the intima, by lymphocyte and other inflammatory cells, causing arteritis. The resultant loss of elastic tissue and its replacement by fibrous tissue leads to progressive thickening and deformity of the arterial wall, causing occlusion, stenosis, dilation or aneurysm formation.  Biopsy of the vessel wall remains the gold standard for diagnosis. Treatment of TA involves the use of corticosteroids and/or immune suppressants such as methotrexate and azathioprine. Chronic use of corticosteroids could lead to adrenal suppression. Our patient was not on immunosuppression or steroid therapy.
In the initial active phase, nearly 60% of patients present with constitutional symptoms but a substantial minority may remain asymptomatic. Progression of the disease results in systemic involvement and symptoms, with or without associated complications such as dizziness, vertigo, visual disturbance, angina, cardiac failure, renal failure, and intermittent claudication, resulting from cerebral, visceral, and extremity ischemia due to stenosis/occlusion of vessels.  The presence of retinopathy, aortic regurgitation and aneurysm formation signal poor prognosis. Five-year mortality varies from 3% to 35%, with heart failure, myocardial infarction and stroke being the commonest cause of death. , Our patient had only developed hypertension, which was controlled by medication.
Ishikawa classified pregnant TA patients into four groups depending upon the severity of associated retinopathy, secondary hypertension, aortic regurgitation, and arterial aneurysm formation.  Group I - no associated complications, Group IIa - one complications with mild severity, Group IIb - one complication with marked severity, and Group III - two or more associated complications. Our patient fell in Group IIa. Hypertension in TA is commonly of renovascular etiology.  Our case did not exhibit any feature of renovascular hypertension.
TA patients present for angioplasty, vascular surgery, obstetrical procedures or incidental surgeries. Revascularization by percutaneous angioplasty, endoprosthesis implantation or surgical correction may be indicated for severe stenosis/occlusion/aneurysm. The extent and distribution of arteritis and resultant damage to organs must be assessed preoperatively. Radiological and biochemical findings must be recorded. In case history for dizziness is elicited, hyperextension of the head during laryngoscopy may worsen cerebral perfusion by stretching of shortened arteries of the neck.  In case numbness in extremities is noted, limb hyperextension during positioning may cause worsen existing poor perfusion.
Our patient had good palpable peripheral pulses, normal renal function tests, and no associated vascular lesion or systemic symptoms. We resorted to routine noninvasive monitoring. However, the SpO 2 could not be monitored after the administration of SAB and a dampened plethysmograph graph was displayed intra-operatively. Since, complications of arterial cannulation are more common in patients with peripheral vasculopathies, it is recommended that invasive blood pressure should be restricted to cases in whom noninvasive blood pressure can't be measured, prolonged surgeries and uncontrolled blood pressure.  As we could not monitor the SpO 2 during the initial phase, placing an arterial line for arterial blood gas analysis is debatable.
Both general anesthesia (GA) and regional anesthesia (RA) have been administered for cesarean section in patients with TA. Administration of both GA and RA may increase morbidity and mortality by reducing organ perfusion worsening the existing ischemia. GA with rapid sequence intubation and a light plane maintained till childbirth may trigger a severe hypertensive response and result in neurological injury. 
A well-managed RA offers better hemodynamic control and facilitates neurological assessment, as the patient is awake. Slow onset of the sympathetic blockade in continuous epidural anesthesia permits regulated fluid loading, preventing hypotension and use of vasopressors.  Combined spinal epidural (CSE) block, with low doses of local anesthetic, is an alternative to continuous epidural anesthesia. However, the local anesthetic spread in CSE, may be high on the administration of the drug in the epidural space, negating the benefits of a low spinal dose. CSE, with epidural volume extension technique, offers rapid onset of spinal anesthesia and the flexibility of epidural anesthesia.  SAB using low dose local anesthetic, spinal opioid, and adequate preloading can be safely performed in patients with TA. 
Neuraxial anesthesia, however, must be avoided in case there is a significant difference between arterial pressures in the upper and lower limbs, as sympathetic block may limit regional blood flow in an unpredictable "steal" type manner.  SAB was found to be safe in an observational study of 24 patients given 7.5 mg bupivacaine.  The difference in blood pressures between the upper and lower limb was recorded as just 10 mm Hg in our case, although a peak systolic gradient of 30 mm Hg had been recorded on aortography 3 years back. We preferred a SAB, using a small dose of local anesthetic supplemented by fentanyl, over epidural anesthesia, as the patient fell in Group IIa, hypertension control was good and a severe fall in blood pressures was not expected after the administration of the SAB.
Fluid loading should be guided by patient's cardiovascular status and can be initiated at the time of the blockade.  Pulmonary edema has been reported after delivery in TA  and so IV fluid preloading was restricted to 600 ml with IV, as overloading can result in cardiac dysfunction. Hypotension, which occurred in the case, was consequent to the fall in heart rate and it was immediately reversed on the administration of atropine. Use of ephedrine or any other vasopressor can result in an abnormal hypertensive response in patients of TA and thus should be avoided. 
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Ioscovich A, Gislason R, Fadeev A, Grisaru-Granovsky S, Halpern S. Peripartum anesthetic management of patients with Takayasu's arteritis: case series and review. Int J Obstet Anesth 2008;17:358-64.
Johnston SL, Lock RJ, Gompels MM. Takayasu arteritis: A review. J Clin Pathol 2002;55:481-6.
Henderson K, Fludder P. Epidural anaesthesia for caesarean section in a patient with severe Takayasu's disease. Br J Anaesth 1999;83:956-9.
Leal Pda C, Silveira FF, Sadatsune EJ, Clivatti J, Yamashita AM. Takayasus's arteritis in pregnancy. Case report and literature review. Rev Bras Anestesiol 2011;61:479-85.
Morales E, Pineda C, Martínez-Lavín M. Takayasu's arteritis in children. J Rheumatol 1991;18:1081-4.
Ishikawa K. Natural history and classification of occlusive thromboaortopathy (Takayasu's disease). Circulation 1978;57:27-35.
Kathirvel S, Chavan S, Arya VK, Rehman I, Babu V, Malhotra N, et al.
Anesthetic management of patients with Takayasu's arteritis: A case series and review. Anesth Analg 2001;93:60-5.
Nasu T. Pathology of pulseless disease. A systematic study and critical review of twenty-one autopsy cases reported in Japan. Angiology 1963;14:225-42.
Choi DH, Kim JA, Chung IS. Comparison of combined spinal epidural anesthesia and epidural anesthesia for cesarean section. Acta Anaesthesiol Scand 2000;44:214-9.
Tiwari AK, Tomar GS, Chadha M, Kapoor MC. Takayasu's arteritis: Anesthetic significance and management of a patient for cesarean section using the epidural volume extension technique. Anesth Essays Res 2011;5:98-101.
Meikle A, Milne B. Extreme arterial blood pressure differentials in a patient with Takayasu's arteritis. Can J Anaesth 1997;44:868-71.
Van Bogaert LJ. Spinal block caesarean section in parturients with pregnancy-induced hypertension. East Afr Med J 1998;75:227-31.
Hauth JC, Cunningham FG, Young BK. Takayasu's syndrome in pregnancy. Obstet Gynecol 1997;50:373-5.
Banerjee A, Stocche RM, Angle P, Halpern SH. Preload or coload for spinal anesthesia for elective Cesarean delivery: A meta-analysis. Can J Anaesth 2010;57:24-31.